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Cervical Cancer
Prevention
in Poor Resource Area :
See & Treat Approach
Dr. Sharda Jain
Director :-
Dr. Aruna Saxrna, MD
• Epidemiology
• Indian scenario
• Concept of See & Treat
(screening & treatment)
• Methods of (VIA & VILLI) screening
• Cryo Cautry
• Colposcopy / Biopsy Guidelines
Schema
Age-standardised incidence and mortality rates:
Indian women
India : Number One
New – 1.32
lakh Deaths -
o.74 lakh
GLOBOCAN 2008
Human
Suffering
Due To
Cervical
Cancer in India
Is depressing•women who die due to Cervical Cancer in
the world is an Indian
1 out of 4
Every 7Minutes,
1 Indian woman dies of Cervical Cancer
Disease Burden
Infact India is a Capital for Cervical Cancer
High Economic Burden
Due to the high number of cervical cancer
cases in the population, it has the highest
total cost of secondary care (100,000 INR
per 100,000 population) relative to all other
cancers.
“Report of the National Commission on Macroeconomics
and Health”, NCMH, Ministry of H &FW, Government of India, August 2005.
Screening- Why?
• In many developed countries, a significant decline
in the incidence of and mortality caused by cervical
cancer has been observed in the past 30 years as a
result of screening by cytology.
• Cervical cancer has precursor, low and high grade
intraepithelial lesion, which has effective treatments
available.
• Screening also gives an opportunity for educating
women who are constantly at high risk.
System Failures Leading to
Cervical Cancer Diagnosis
Women do not
come in for
screening
Health care providers
do not screen women
at visits
Colposcopy for
abnormal screen
not done
Patient does not get
appropriate therapy
Patient gets cervical
cancer
Courtesy of Connie Trimble, MD, Johns Hopkins University School of Medicine, Baltimore, MD
Cancer Cervix –
a Global Paradox
• Cancer cervix –100% Preventable disease
WHO
• Cancer cervix –Death by incompetence
Lancet
• Cancer cervix – the unmet challange
Disease Progression
Disease Regression
Natural History of Cervical Cancer
HPV
infection
CIN 1
CIN 2,3
HPV
disappearance
Invasive CA
Avg. 10-13 yrs
Avg. 6-
24 mo
Avg. 6-
12 mo.
AGE SCREENING
< 21 No Screening
21-29 Cytology alone every 3 years
30-65 Acceptable: Cytology alone every 3 years*
Preferred ??: Cytology + HPV every 5 years* OR
> 65 No screening, following 3 consequetive neg prior
screens in last decade
After total hysterectomy No screening, if no history of CIN2+ in the past 20
years of cervical cancer ever
HIV-positive
-Immunosuppressed (e.g., Annually
2013 Guidelines
for prevention of Cervical cancer
• 1st
time that all 3 organizations involved with cervical cancer prevention and the
USPSTF have endorsed equivalent guidelines
Type of screening
• Conventional cytology
• Liquid-based monolayer cytology
• Human papillomavirus testing
• Testing in resource-poor areas
Testing in
Resource-Poor areas
• Pap smears require skilled practitioners and
good laboratories to be effective,
• Most studies have found that VIA, and its
cousin VILI -- visual inspection with Lugol's
iodine -- are somewhat less specific than Pap
smears, but more sensitive
Overall, VIA seems to be an excellent
cervical cancer screening method for
use in low-resource settings where
Pap smears and HPV tests are
inappropriate due to either lack of
expertise or high per-test cost.
The general consensus is that
VIA is just as useful as the Pap
smear; it's just a matter of
determining which one is more
appropriate in any given
circumstance based on
availability of funds & trained
personnel for screening and
follow up
VIA generally detects more early
lesions but is associated with more
false positives.
This could conceivably lead to over
treatment, but in low-resource areas
where large numbers of women are
still dying of cervical cancer, some
governments have decided it is a
worthwhile trade-off. (African Countries)
in India ICPO( institute of cytology
and preventive oncology) took
initiative in developing simple
strategies like VIA in1980’s ,which
subsequently supported by other
international agencies like
IARC,LYON,FRANCE,JHPIEGO,a
nd PATH in USA etc.
India
Screening – not even tip of iceberg
GOI – has
O MONEY
for
universal
vaccination
Screening women at rural & slums
settings and following them is tedious
task for Gynaecologists
But
Motivating them once,examining and
treating them simultaneously if any
abnormality noted, can be easier
task to prevent cervical cancer!
Logic Behind See & Treat Approach
What is basics behind
VIA
Accesibility of CERVIX……..
• seen instantly after putting speculum inside the vagina
and becomes apparent.
• The success of VIA lies in visualising the cervix in the
region of transformation zone in its entirely.
TZ lies between the original squamo-columner junction
and the new (or the present ) squamo-columner junction.
This is a highly active zone of metaplastic tissues in
which the single layered columnar epithelium is transformed
by metaplastic cellular divisions into multilayered squamous
epithelium.
metaplasia and what triggers it
• Exposure of columnar epithelium during ectropion to
acidic environment of vagina leads to metaplasia.(healing
process of damaged columnar epithelium)
• Region that has undergone metaplasia is transformation
zone, bound distally by SCJ E and proximally by SCJ M,
is region of mitosis as cells are
rapidly dividing during metaplasia.
The mitotic rate is higher near SCJ M That's why it
appears white with acetic acid
E
Understanding of “Transformation Zone”
squamous epitheliumsquamous epithelium
ectocervixectocervix endocervixendocervix
SCJSCJ
GLAND OPENINGS in TZ
NYBOTHIAN
FOLLICLE
In TZ
SCJ in various ages
VIA
• Naked eye visual inspection of
cervix, after application of 3-5%
acetic acid to detect pre cancer
lesions is VIA
VIAC
• Magnifying cervix with an ordinary
lens is VIAC i.e visual inspection with
acetic acid aided by cervicography
VIAM
• Technique: is same as that of VIA but
viewning of cervix is done with magnifying
glasses of 4 mm
• Studies from South Africa and Kolkatta, India
have reported no benefit of VIAM over VIA
• Study from TMH also concluded same.
All of us can do it and
also can train our staff to
screen large number of
women with very little
cost
VIA
VIA & VILI
PROCEDURES
PATIENT POSITION
Lithotomy
Position
Consent
Time
STEPS FOR PERFORMING VIA
• Normal Inspection after cleaning with
normal saline
• Inspection after application of acetic acid
• Inspection after application of lugols Iodine
• Examination of Vagina
NORMAL INSPECTION AFTER CLEANING
WITH NORMAL SALINE….
ACETIC ACID TEST
• Coagulation of cell protein seen an interval of 1 mint.
• If white layer is very thick (opaque) that area becomes
area of concern.
• The impact of acetic acid fades away normally in 1-3 mints,
So repeated application is recommended for proper
visualization of pathological lesions.
Aceto white lesion
• Intensity
• Duration of stay
• speed of Appearance
• speed of disappearance
• margins Relation to SCJ
Inside TZ/ outside TZ
Grading of VIA Findings….
• Grade I: Flat acetowhite epithelium, snow white,
regular pattern
• Grade II: Flat but whiter acetowhite epithelium, gray
white,
• Grade-III dull oyster white,
Pre cancer lesions of cervix on VIA
Appearance
white translucent
ivory white
egg white with thick areas
remains for longer time
Margins
sharp and distinct
internal margins
Surface contour
Flat or raised
Abnormal vascular patterns
punctations
Wide inter capillary distance
Extent
Confined to TZ
Disappearing into
cervical canal
% of TZ involved
Satellite lesion
VIA and cervical cancer
screening
• 4% acetic acid is applied to cervix with the help of a cotton
pad after removing excess mucus.
• VIA recording 1 minute after application of acid.
• Positive result: acetowhite areas in the squamocolumnar
junction, or entire cervix or a growth over cervix
• WHITE PATCHES” appears due
to coagulation of cellular proteins and
indicate the abnormal epithelium.
VIA and cervical cancer
• What does positive VIA mean:
• Infection
• Dysplasia
• Intraepithelial lesion
• Cancer
• So, final conclusion is done by colposcopy
and biopsy which is the gold standard.
Effect of visual inspection with acetic acid (VIA)
screening by primary health workers on cervical
cancer mortality: A cluster randomized controlled
trial in Mumbai, India. 2013 ASCO Annual Meeting
Surendra Srinivas Shastri, Indraneel Mittra, Gauravi
Mishra, Subhadra Gupta, Rajesh Dikshit, Rajendra A.
Badwe; Tata Memorial Centre, Mumbai, India
Plenary Session, Plenary Session Including FDA Commissioner Address,
Public Service Award, and Science of Oncology Award and Lecture
• Cluster-randomized controlled trial in 1998 to investigate the efficacy of
VIA screening by primary health workers (PHWs) in reducing cervical
cancer mortality.
• Women aged 35-64 years with no prior history of cancer were included
• 20 clusters with an average of 7,500 eligible women per cluster.
• Four rounds of cancer education and VIA screening were conducted by
PHWs in the screening group, while cancer education was offered
once at recruitment to the control group
• Recruitment was completed in March 31, 2002. Analysed the results
at 12 years
• Recruited 75,360 women from 10 clusters in the
screening group and 76,178 women from 10
comparable clusters in the control group
Results
• The analysis is on an intention-to-treat basis.
• In the screening group, achieved 89% participation for screening and
79% compliance for post-screening diagnostic confirmation.
• The quality of screening by PHWs was comparable to that of an expert
gynecologist (κ=0.84).
• The incidence of invasive cervical cancer was 26.74 per 100,000 in the
screening group and 27.49 per 100,000 in the control group.
•
• The screening group showed a 31% reduction in cervical cancer
mortality (p=0.003) compared to the control group.
• A 7% reduction was also observed in all-cause mortality .
Conclusions
• VIA screening conducted by PHWs
significantly reduced cervical cancer
mortality.
• VIA screening is easily implementable
and could prevent 22,000 cervical cancer
deaths in India.
VILI
• Technique is same as that of VIA but instead of acetic acid, lugol’s
iodine is applied to cervix and end result is change in color to yellow
over positive areas.
• Sankaranarayanan et al did a multicenter study in South Africa and
India on VILI and screening of cervical cancer.
• Sensitivity of VILI turned out to be 86.7-90%.
• Authors gave the reason of such high sensitivity of VILI: the
yellow color changes associated with a positive VILI test result
are more easily recognized by the health workers compared with
the acetowhite changes associated with VIA.
Best Pract Res Clin Obstet Gynaecol. 2012
Mustard yellow
Making Gynaecologists
aware of common
cervical lesions
Treatment of pre cancer
lesions of cervix
• Cryo therapy
• Leep
• biopsy
Cryo therapy
Cryotherapy
• Cryotherapy destroys abnormal
tissue on the cervix by freezing it by
cold coagulation using ice cold gas .
• gases can destroy cells upto 3 mm
by co2 and 5 mm by nitrous oxide.
advantages
• Safe
• One visit treatment
• OPD procedure
• No anaesthesia
• No adverse effects on reproduction
LEEP
• Large loop electrical procedure
Criteria for LEEP
AWL covering > 75% of TZ
Lesion with abnormal blood vessels
Persistent lesion after cryo
Disparity between cytology, VIAC and
histology
Limits of lesion not visible.
To conclude
•Cervical cancer is a preventable cancer .
•We as gynecologists can do a lot to make
an impact to decrease this disease burden.
•See and treat can be a successful mantra
in our country if all gynecologists come
forward to give their due contribution to this
country where they have been trained.
Now this is our turn to give back

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Cervical Cancer Prevention in Poor Resource areas : See & treatapproach dr. sharda jain.ppt corrected

  • 1. Cervical Cancer Prevention in Poor Resource Area : See & Treat Approach Dr. Sharda Jain Director :- Dr. Aruna Saxrna, MD
  • 2. • Epidemiology • Indian scenario • Concept of See & Treat (screening & treatment) • Methods of (VIA & VILLI) screening • Cryo Cautry • Colposcopy / Biopsy Guidelines Schema
  • 3. Age-standardised incidence and mortality rates: Indian women India : Number One New – 1.32 lakh Deaths - o.74 lakh GLOBOCAN 2008
  • 4. Human Suffering Due To Cervical Cancer in India Is depressing•women who die due to Cervical Cancer in the world is an Indian 1 out of 4
  • 5. Every 7Minutes, 1 Indian woman dies of Cervical Cancer Disease Burden Infact India is a Capital for Cervical Cancer
  • 6. High Economic Burden Due to the high number of cervical cancer cases in the population, it has the highest total cost of secondary care (100,000 INR per 100,000 population) relative to all other cancers. “Report of the National Commission on Macroeconomics and Health”, NCMH, Ministry of H &FW, Government of India, August 2005.
  • 7. Screening- Why? • In many developed countries, a significant decline in the incidence of and mortality caused by cervical cancer has been observed in the past 30 years as a result of screening by cytology. • Cervical cancer has precursor, low and high grade intraepithelial lesion, which has effective treatments available. • Screening also gives an opportunity for educating women who are constantly at high risk.
  • 8. System Failures Leading to Cervical Cancer Diagnosis Women do not come in for screening Health care providers do not screen women at visits Colposcopy for abnormal screen not done Patient does not get appropriate therapy Patient gets cervical cancer Courtesy of Connie Trimble, MD, Johns Hopkins University School of Medicine, Baltimore, MD
  • 9. Cancer Cervix – a Global Paradox • Cancer cervix –100% Preventable disease WHO • Cancer cervix –Death by incompetence Lancet • Cancer cervix – the unmet challange
  • 12. Natural History of Cervical Cancer HPV infection CIN 1 CIN 2,3 HPV disappearance Invasive CA Avg. 10-13 yrs Avg. 6- 24 mo Avg. 6- 12 mo.
  • 13. AGE SCREENING < 21 No Screening 21-29 Cytology alone every 3 years 30-65 Acceptable: Cytology alone every 3 years* Preferred ??: Cytology + HPV every 5 years* OR > 65 No screening, following 3 consequetive neg prior screens in last decade After total hysterectomy No screening, if no history of CIN2+ in the past 20 years of cervical cancer ever HIV-positive -Immunosuppressed (e.g., Annually 2013 Guidelines for prevention of Cervical cancer • 1st time that all 3 organizations involved with cervical cancer prevention and the USPSTF have endorsed equivalent guidelines
  • 14. Type of screening • Conventional cytology • Liquid-based monolayer cytology • Human papillomavirus testing • Testing in resource-poor areas
  • 16. • Pap smears require skilled practitioners and good laboratories to be effective, • Most studies have found that VIA, and its cousin VILI -- visual inspection with Lugol's iodine -- are somewhat less specific than Pap smears, but more sensitive
  • 17. Overall, VIA seems to be an excellent cervical cancer screening method for use in low-resource settings where Pap smears and HPV tests are inappropriate due to either lack of expertise or high per-test cost.
  • 18. The general consensus is that VIA is just as useful as the Pap smear; it's just a matter of determining which one is more appropriate in any given circumstance based on availability of funds & trained personnel for screening and follow up
  • 19. VIA generally detects more early lesions but is associated with more false positives. This could conceivably lead to over treatment, but in low-resource areas where large numbers of women are still dying of cervical cancer, some governments have decided it is a worthwhile trade-off. (African Countries)
  • 20. in India ICPO( institute of cytology and preventive oncology) took initiative in developing simple strategies like VIA in1980’s ,which subsequently supported by other international agencies like IARC,LYON,FRANCE,JHPIEGO,a nd PATH in USA etc.
  • 21. India Screening – not even tip of iceberg
  • 22. GOI – has O MONEY for universal vaccination
  • 23. Screening women at rural & slums settings and following them is tedious task for Gynaecologists But Motivating them once,examining and treating them simultaneously if any abnormality noted, can be easier task to prevent cervical cancer! Logic Behind See & Treat Approach
  • 24. What is basics behind VIA
  • 25. Accesibility of CERVIX…….. • seen instantly after putting speculum inside the vagina and becomes apparent. • The success of VIA lies in visualising the cervix in the region of transformation zone in its entirely.
  • 26. TZ lies between the original squamo-columner junction and the new (or the present ) squamo-columner junction. This is a highly active zone of metaplastic tissues in which the single layered columnar epithelium is transformed by metaplastic cellular divisions into multilayered squamous epithelium.
  • 27. metaplasia and what triggers it • Exposure of columnar epithelium during ectropion to acidic environment of vagina leads to metaplasia.(healing process of damaged columnar epithelium) • Region that has undergone metaplasia is transformation zone, bound distally by SCJ E and proximally by SCJ M, is region of mitosis as cells are rapidly dividing during metaplasia. The mitotic rate is higher near SCJ M That's why it appears white with acetic acid
  • 28. E
  • 29. Understanding of “Transformation Zone” squamous epitheliumsquamous epithelium ectocervixectocervix endocervixendocervix SCJSCJ
  • 33. VIA • Naked eye visual inspection of cervix, after application of 3-5% acetic acid to detect pre cancer lesions is VIA VIAC • Magnifying cervix with an ordinary lens is VIAC i.e visual inspection with acetic acid aided by cervicography
  • 34. VIAM • Technique: is same as that of VIA but viewning of cervix is done with magnifying glasses of 4 mm • Studies from South Africa and Kolkatta, India have reported no benefit of VIAM over VIA • Study from TMH also concluded same.
  • 35. All of us can do it and also can train our staff to screen large number of women with very little cost VIA
  • 38.
  • 39. STEPS FOR PERFORMING VIA • Normal Inspection after cleaning with normal saline • Inspection after application of acetic acid • Inspection after application of lugols Iodine • Examination of Vagina
  • 40. NORMAL INSPECTION AFTER CLEANING WITH NORMAL SALINE….
  • 41. ACETIC ACID TEST • Coagulation of cell protein seen an interval of 1 mint. • If white layer is very thick (opaque) that area becomes area of concern. • The impact of acetic acid fades away normally in 1-3 mints, So repeated application is recommended for proper visualization of pathological lesions.
  • 42. Aceto white lesion • Intensity • Duration of stay • speed of Appearance • speed of disappearance • margins Relation to SCJ Inside TZ/ outside TZ
  • 43. Grading of VIA Findings…. • Grade I: Flat acetowhite epithelium, snow white, regular pattern • Grade II: Flat but whiter acetowhite epithelium, gray white, • Grade-III dull oyster white,
  • 44. Pre cancer lesions of cervix on VIA Appearance white translucent ivory white egg white with thick areas remains for longer time Margins sharp and distinct internal margins Surface contour Flat or raised Abnormal vascular patterns punctations Wide inter capillary distance Extent Confined to TZ Disappearing into cervical canal % of TZ involved Satellite lesion
  • 45. VIA and cervical cancer screening • 4% acetic acid is applied to cervix with the help of a cotton pad after removing excess mucus. • VIA recording 1 minute after application of acid. • Positive result: acetowhite areas in the squamocolumnar junction, or entire cervix or a growth over cervix • WHITE PATCHES” appears due to coagulation of cellular proteins and indicate the abnormal epithelium.
  • 46. VIA and cervical cancer • What does positive VIA mean: • Infection • Dysplasia • Intraepithelial lesion • Cancer • So, final conclusion is done by colposcopy and biopsy which is the gold standard.
  • 47. Effect of visual inspection with acetic acid (VIA) screening by primary health workers on cervical cancer mortality: A cluster randomized controlled trial in Mumbai, India. 2013 ASCO Annual Meeting Surendra Srinivas Shastri, Indraneel Mittra, Gauravi Mishra, Subhadra Gupta, Rajesh Dikshit, Rajendra A. Badwe; Tata Memorial Centre, Mumbai, India Plenary Session, Plenary Session Including FDA Commissioner Address, Public Service Award, and Science of Oncology Award and Lecture
  • 48. • Cluster-randomized controlled trial in 1998 to investigate the efficacy of VIA screening by primary health workers (PHWs) in reducing cervical cancer mortality. • Women aged 35-64 years with no prior history of cancer were included • 20 clusters with an average of 7,500 eligible women per cluster. • Four rounds of cancer education and VIA screening were conducted by PHWs in the screening group, while cancer education was offered once at recruitment to the control group • Recruitment was completed in March 31, 2002. Analysed the results at 12 years • Recruited 75,360 women from 10 clusters in the screening group and 76,178 women from 10 comparable clusters in the control group
  • 49. Results • The analysis is on an intention-to-treat basis. • In the screening group, achieved 89% participation for screening and 79% compliance for post-screening diagnostic confirmation. • The quality of screening by PHWs was comparable to that of an expert gynecologist (κ=0.84). • The incidence of invasive cervical cancer was 26.74 per 100,000 in the screening group and 27.49 per 100,000 in the control group. • • The screening group showed a 31% reduction in cervical cancer mortality (p=0.003) compared to the control group. • A 7% reduction was also observed in all-cause mortality .
  • 50. Conclusions • VIA screening conducted by PHWs significantly reduced cervical cancer mortality. • VIA screening is easily implementable and could prevent 22,000 cervical cancer deaths in India.
  • 51. VILI • Technique is same as that of VIA but instead of acetic acid, lugol’s iodine is applied to cervix and end result is change in color to yellow over positive areas. • Sankaranarayanan et al did a multicenter study in South Africa and India on VILI and screening of cervical cancer. • Sensitivity of VILI turned out to be 86.7-90%. • Authors gave the reason of such high sensitivity of VILI: the yellow color changes associated with a positive VILI test result are more easily recognized by the health workers compared with the acetowhite changes associated with VIA. Best Pract Res Clin Obstet Gynaecol. 2012
  • 53. Making Gynaecologists aware of common cervical lesions
  • 54. Treatment of pre cancer lesions of cervix • Cryo therapy • Leep • biopsy
  • 56. Cryotherapy • Cryotherapy destroys abnormal tissue on the cervix by freezing it by cold coagulation using ice cold gas . • gases can destroy cells upto 3 mm by co2 and 5 mm by nitrous oxide.
  • 57. advantages • Safe • One visit treatment • OPD procedure • No anaesthesia • No adverse effects on reproduction
  • 58. LEEP • Large loop electrical procedure Criteria for LEEP AWL covering > 75% of TZ Lesion with abnormal blood vessels Persistent lesion after cryo Disparity between cytology, VIAC and histology Limits of lesion not visible.
  • 59. To conclude •Cervical cancer is a preventable cancer . •We as gynecologists can do a lot to make an impact to decrease this disease burden. •See and treat can be a successful mantra in our country if all gynecologists come forward to give their due contribution to this country where they have been trained. Now this is our turn to give back

Editor's Notes

  1. He first reported that uterine cancer could be diagnosed by means of a vaginal smear in 1928, but the importance of his work was not recognized until the publication, together with Herbert Traut, of  Diagnosis of Uterine Cancer by the Vaginal Smear  in 1943. The book discusses the preparation of vaginal and cervical smears, physiologic cytologic changes during the  menstrual cycle , the effects of various pathological conditions, and the changes seen in the presence of  cancer  of the  cervix  and of the  endometrium  of the  uterus . He thus became known for his invention of the Papanicolaou test, commonly known as the  Pap smear  or  Pap test , which is used worldwide for the detection and prevention of cervical cancer and other cytologic diseases of the female reproductive system. In 1961 he moved to Miami, Florida, to develop the Papanicolaou Cancer Research Institute at the University of Miami, but died in 1962 prior to its opening. Papanicolaou was the recipient of the Albert Lasker Award for Clinical Medical Research in 1950. [3] Papanikolaou&apos;s portrait appeared on the obverse of the Greek 10,000-drachma banknote of 1995-2001, [4]  prior to its replacement by the Euro. In 1978 his work was honored by the U.S. Postal Service with a 13-cent stamp for early cancer detection.